Provider Demographics
NPI:1912398322
Name:WHALEN THERAPEUTIC CENTER PLLC
Entity type:Organization
Organization Name:WHALEN THERAPEUTIC CENTER PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICIAN/SCHOOL PSYCHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:LPC05538
Authorized Official - Phone:918-264-4365
Mailing Address - Street 1:9195 E 580 RD
Mailing Address - Street 2:
Mailing Address - City:CATOOSA
Mailing Address - State:OK
Mailing Address - Zip Code:74015
Mailing Address - Country:US
Mailing Address - Phone:918-739-0340
Mailing Address - Fax:888-975-3464
Practice Address - Street 1:1801 HWY 66
Practice Address - Street 2:
Practice Address - City:CATOOSA
Practice Address - State:OK
Practice Address - Zip Code:74015
Practice Address - Country:US
Practice Address - Phone:918-264-4365
Practice Address - Fax:888-975-3464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-07
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5538101YP2500X, 101YM0800X
KS2394101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200402920BMedicaid
KS201122950AMedicaid
OK200575340AMedicaid